A19MSOH White copy = Submit with the application A19MSOH Yellow Copy = Leave with the Medicare-eligible beneficiary (applicant)

American Family Life Assurance Company of Columbus herein referred to as Aflac

Worldwide Headquarters • Columbus, Georgia 31999 Administration: [P.O. Box 1553]

[Pensacola, Florida 32591] [1.855.207.2078]

MEDICARE SUPPLEMENT INSURANCE SOLICITATION NOTICE

1. The person making this solicitation is an Ohio-licensed insurance agent.

2. You may verify the agent’s license by contacting:

The Ohio Department of Insurance Toll-free: 800-686-1526 50 West Town Street, Suite 300 TDD: 614-644-3745 Columbus, Ohio 43215 www.ohioinsurance.gov 3. Aflac is the insurer issuing the Medicare supplement insurance policy. You may contact the insurance

company at:

American Family Life Assurance Company of Columbus Worldwide Headquarters • Columbus, Georgia 31999

Administration: [P.O. Box 1553] [Pensacola, Florida 32591]

[1.855.207.2078]

4. Neither Aflac nor the agent/broker making this solicitation have any connection or affiliation with, and are not in any way sponsored by, the federal or state government, the Social Security Administration, the Centers for Medicare and Medicaid services, or the Department of Health and Human Services.

5. If you decide to purchase a Medicare supplement health insurance plan, you have the option of paying the premium directly to the insurance company.

This is to confirm that the undersigned agent has read this notice and provided a copy of this notice to the Medicare-eligible beneficiary whose signature appears below on this ________day of _______________________, 20_____. Agent Signature: __________________________________________________________________ Agent Printed Signature: ____________________________________________________________ Ohio Insurance License Number: _____________________________ Agent Address: ____________________________________________________________________ Street Address City State Zip Code Telephone: _______________________________________________________ Applicant Signature: _______________________________________________ Applicant Printed Signature: ________________________________________ Agent Instructions: You must read and provide the carbon copy of this notice to the Medicare-eligible beneficiary (applicant) at the time of solicitation for a Medicare supplement insurance policy. The original copy of this notice must be submitted with the application. You and beneficiary must sign, acknowledging the notice was presented both orally and in writing to the Medicare beneficiary (applicant).